A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip.
Which data is most important for the nurse to monitor?

Client's hourly blood pressure.

Preparation for emergency cesarean birth.

Checking the perineum for bulging.

Intensity, interval, and length of contractions.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Monitoring hourly blood pressure is essential, but it is not the most crucial data in this scenario. Blood pressure monitoring can help identify maternal hypotension or hypertension, which can affect uteroplacental blood flow. However, hypotonic dystocia requires monitoring contractions to assess labor progression and effectiveness of oxytocin.

Choice B rationale

Preparing for an emergency cesarean birth is a potential intervention if labor does not progress or if fetal distress occurs. However, it is not the primary data to monitor initially. The decision for a cesarean is based on a comprehensive assessment, including fetal heart rate patterns and contraction quality.

Choice C rationale

Checking the perineum for bulging may indicate imminent delivery or fetal descent. However, in the context of hypotonic dystocia, the primary concern is evaluating contraction patterns to ensure the effectiveness of oxytocin in augmenting labor.

Choice D rationale

Monitoring the intensity, interval, and length of contractions is the most critical data in this case. Hypotonic dystocia involves weak, infrequent, or irregular contractions. Oxytocin is administered to strengthen and regularize contractions, so assessing their characteristics is crucial to determine the response to treatment and guide further interventions.

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Correct Answer is B

Explanation

Choice A rationale

While vitamin K is indeed administered to newborns to help with blood clotting, it is given intramuscularly (IM) and not subcutaneously (SUBQ). Subcutaneous injections are not typically used for administering vitamin K to newborns due to absorption issues.

Choice B rationale

Vitamin K is given to newborns to prevent bleeding disorders, as they are born with low levels of this essential vitamin. This is a standard practice to prevent Vitamin K Deficiency Bleeding (VKDB) in newborns.

Choice C rationale

Blood drawing is a common procedure in newborns, but it usually involves a heel stick, not a needle mark in the thigh. Hemoglobin and hematocrit levels are generally checked to assess the baby's blood count, not for vitamin K administration.

Choice D rationale

While the thigh is a common site for injections in infants, this response does not address the mother's concern about the specific reason for the needle mark. It is important to provide a clear and direct explanation.

A. "You may be at higher risk for having a spontaneous miscarriage.”. B. "You may have an increased chance of having preeclampsia.”. C. "This medication will have no effect on your unborn child.”. D. "You may experience postpartum hemorrhaging after delivery.”.

Correct Answer is A

Explanation

Choice A rationale

Misoprostol is a synthetic prostaglandin E1 (PGE1) analog that can induce uterine contractions, increasing the risk of a spontaneous miscarriage, particularly in early pregnancy.

Choice B rationale

Misoprostol is not known to increase the risk of preeclampsia. Preeclampsia involves high blood pressure and potential damage to other organ systems, typically appearing after 20 weeks of pregnancy.

Choice C rationale

Misoprostol does have an effect on the unborn child due to its ability to cause uterine contractions and cervical ripening, potentially leading to miscarriage.

Choice D rationale

Misoprostol is not associated with an increased risk of postpartum hemorrhaging after delivery. It is often used to manage postpartum hemorrhage by promoting uterine contractions.

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Naxlex Comprehensive Predictor Exams

A new mother asks the nurse why her infant son has a needle mark on his leg.Which response is best for the nurse to provide this mother?

Correct Answer is B

Explanation

A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug.How should the nurse respond?

Correct Answer is A

Explanation

When reading the obstetrical history of a client who is currently at 36 weeks gestation, the nurse notes that she has had one full-term infant, one premature infant born at 32 weeks gestation that survived, and one miscarriage.Which is this client's gravidity?

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4°F (38°C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.Which technique should the nurse implement to evaluate the leakage?

The nurse is caring for a postpartum client who delivered 5 hours ago, and has saturated a perineal pad with clots within the last 15 minutes.Which action is most important for the nurse to implement?

During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks.The nurse notes the client has 3+ bilateral, pitting, pedal edema.Which action should the nurse implement?

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?

A nurse is caring for a 34-year-old female client in the labor and delivery unit. Exhibits The nurse evaluates the client’s progress. Review the findings below and determine if each one is normal or abnormal.

A client at 37 weeks gestation presents with contractions every 3 to 4 minutes, lasting 60 seconds.The fetal heart rate is noted to be 140 bpm, and no abnormal fetal movements are observed.The client reports no pain and normal laboratory results.Which action should the nurse implement first?